The short story follows a woman who has been sent by her physician to a colonial mansion in the country as treatment for postpartum depression. The woman, who remains nameless, is constantly dismissed and belittled by her husband, who is also a physician. He speaks to her patronizingly and ignores her protestations that the “treatment” she is being given is making her worse instead of better. She is told not to think, and not to write, and her husband believes that since he sees no reason for her suffering, it does not exist. She is kept upstairs in the mansion’s nursery, isolated behind bars and gates that she believes to be there for children’s safety, when in actuality they function to keep her imprisoned. As time passes, the woman believes that she perceives something in the wallpaper and becomes convinced that it is a trapped woman. She believes the woman is confined behind bars within the wallpaper, which mirrors the trapped feelings that she herself is experiencing living day in and day out inside the confines of the nursery. Her desire to help the woman escape, which mounts to a frenzy, is reflective of her own desire to be free from the nursery and the rest cure.

Throughout the story, the titular wallpaper functions almost as another character as it’s brought to life in the narrator’s mind. She contrasts the vitality of the wallpaper with the “dead paper” upon which she is writing the journal entries that make up the narrative. Her fascination, and disgust, with the wallpaper drive the story as she investigates its pattern and condition, and then ultimately determines that there is someone living within it. The narrator’s disdain for the paper is obvious in her descriptions; for instance, in her first mention of the wallpaper, she writes “I never saw a worse paper in my life” (p. 793). She later writes that the print was “One of those sprawling flamboyant patterns committing every artistic sin” (p. 793). On the topic of its hue, she writes that “The color is repellent, almost revolting; a smouldering unclean yellow…a dull yet lurid orange in some places, a sickly sulphur tint in others” (p. 793). For all of her disgust with the wallpaper, and its damaged and torn condition, she still finds herself fascinated by it, and this fascination turns into obsession, which later turns into madness.

“The Yellow Wallpaper” works so effectively because it allows the reader to step into the mind of a woman as she is driven to madness. The structure of the story, which is told in an epistolary format, adds to the reader’s affiliation with the narrator as there is an intimacy in reading her journal entries and being in on the secret that she is writing against her husband’s orders. This affiliation helps to build empathy between the reader and the narrator, which contributed to the concern that I felt for the woman when she slowly lost her mind. If the story helped to save people, as Gilman hoped, it did so because it made them see the human being at the center of the “illness” and “treatment,” forcing them to understand what truly happens when you isolate someone and take away their ability to do what brings them joy. We bear witness as the woman loses her mind, leaving us with an intimate picture of what the rest “cure” could truly do to someone’s psyche. Instead of viewing postpartum depression solely as a condition to be treated, “The Yellow Wallpaper” makes readers realize that there is a person at the center whose needs and voice deserve attention.

In a patriarchal era in which women’s voices and lived experiences were ignored in favor of what the men around them deemed to be “best,” “The Yellow Wallpaper” offers an important and valuable perspective – that of the woman herself. By placing the female patient’s voice at the forefront of her story, Gilman gives her narrator the agency that had previously been stripped from her, to tell the story of her postpartum depression and how the prescribed treatment drove her to madness instead of restoring her health. It is a reminder to each of us that the voice of the patient is of paramount importance in any instance in which an embodied condition is being treated. When we ignore the patient, and what they need, they are lost, pushed to the background, and left to disappear into their own metaphorical wallpapers.

Works Cited
Gilman, Charlotte Perkins. “The Yellow Wallpaper.” The Norton Anthology of American Literature, edited by Nina Baym and Robert S. Levine, W.W. Norton & Company, 2012, pp. 804.

Originally published by The New England Magazine, Boston, 1892

Image Credits
Illustration for ”The Yellow Wall-paper” by Joseph Henry Hatfield, 1892 from Wiki Commons
Book cover by Small, Maynard & Company, 1901 from Wiki Commons
Web image from Medhum

Film ReviewVideo

Obsession and “The Yellow Wallpaper” 

Rudy Malcom May 29, 2026

The film highlights the peril of love that demands possession.

Henry’s severe illness and his difficulties accessing treatment prompted Green to contemplate the horrifying statistics of tuberculosis and the paradox of our extensive knowledge about it. More than one million people still die every year from this ancient disease; yet the bacterial cause was elucidated a century and a half ago, and effective treatments have been around since the 1950s. Barring eradication, the germs mutate and become resistant. Given dire living conditions, it spreads. Effective therapy can be prohibitively expensive. “The cure is where the disease is not, and the disease is where the cure is not” (p. 5). People die where cures cannot be obtained. 

History is woven though Henry’s story, but so are politics, culture, and economics: the discoveries, the 19^th-century romanticization of ‘wasting away,’ the hard realities of pharmaceutical development and delivery. Henry has survived, become healthy and an inveterate TikToker and youtuber. He even has an episode on the power of storytelling. But other people that we encounter through this tale have died. 

We still have tuberculosis because statistics de-personify it, and geography allows ignoring it. Green uses Henry’s story to invite us to ‘[t]hink about how rare and precious humans are, and how many of them you get to worry for and care about. Then if you can, find a way to multiply that 1,250,000 times’ (p. 189).  

The book flows easily in language that is clear and accessible, a tribute to Green’s experience in writing young-adult fiction. In the end, without denying the benefits of medical interventions, he calls for a focus on the real cause of tuberculosis: injustice—tolerated and unchallenged. ‘Ultimately,’ he writes, ‘we are the cause’ (p. 184).  

Everything is Tuberculosis: The History and Persistence of Our Deadliest Infection
John Green
New York: Penguin/Crash Course Books
2025
ISBN 9780525556572 

Web image created by Medhum.org

Many modern physicians minimize, or are unaware of, a second source of historical medical success: the power of language and ritual to facilitate physical and psychological healing. Assisted by his priests, Aesculapius, the Greek god of medicine, healed the sick through poetry, narrative, and ritual. Even Hippocrates, the father of naturalistic Western medicine, paid tribute to Aesculapius in his famous Oath, and emphasized in many of his case histories the importance of interpersonal and contextual factors in patient care. While the healing power of language and context was rarely explicit in the subsequent history of Western medicine, it finally emerged into consciousness during the last two hundred years, when it was given the name placebo effect. Initially considered a minor aberration in suggestible people, more recently this component of healing has been recognized as an almost universal human facility (or reaction) of varying and sometimes amazing power.  

In this essay I present a case study of a traditional healing ceremony in which the therapy consists entirely of language, especially poetry, and the ritual context in which the language is spoken and chanted. I argue that this is a very powerful example of contextual healing. I then examine our contemporary understanding of the placebo effect, which is also a form of contextual healing, albeit ordinarily much less striking and more “dilute” than the Navajo example. Finally, I comment briefly on some features of healing miracles in the Catholic Church, arguing that these, too, are powerful instances of contextual healing that suggest at their upper limit, so to speak, such mechanisms may actually be able to reverse disease processes, like cancer or neurological impairment. Of course, this outcome is rare, unpredictable, and not at all understood.  

Sarah Mailcarrier and the Night Way 

Dark cloud is at the door. 
The trail out of it is dark cloud. 
The zigzag lightning stands high upon it. 
An offering I make. 
Restore my feet for me. 
Restore my legs for me. 
Restore my body for me. 
Restore my mind for me. 
Restore my voice for me. 
This very day take out your spell for me.  

Happily, I recover. 
Happily my interior becomes cool. 
Happily I go forth. 
My interior feeling cool, may I walk. 
No longer sore, may I walk. 
Impervious to pain, may I walk. 
With lively feelings may I walk. 
As it used to be long ago, may I walk.¹ 

These lines constitute a small segment from one of the poems chanted during the Night Way, a nine-day Navajo healing ceremony. In the early 1970s, Sarah Mailcarrier was the matriarch of an extended family whose camp was at Cornfields in Beautiful Valley near Klagetoh Mesa. A healthy woman well into her 60s, she developed severe lower abdominal pain, vaginal bleeding, poor appetite, and swelling of her legs over a period of two to three months. Her family took her to Fort Defiance Indian Hospital, some 50 miles from home, where she was discovered to be suffering from cancer of the cervix, which had spread widely, blocking lymphatic ducts in her legs and partially obstructing her kidneys. The recommended treatment was palliative radiation at Gallup Indian Medical Center, a larger hospital in Gallup, New Mexico, another 30 miles distant from Cornfields. Sarah and her family declined this option and, instead, consulted a hand trembler, who diagnosed her problem and recommended a Night Way Sing or healing ceremony. The family hired a ha’a’tali or traditional healer who, along with his assistants, conducted the ceremony over nine days and nights at her camp in Cornfields.² 

According to Navajo diagnostic taxonomy, Sarah had fallen out of harmony with the cosmic narrative that defines the proper relationships among the Earth Surface People, the Holy People, and the natural world. This likely was the result of certain traumatic exposures and events in her life. Healing would require restoration of harmony through the chants, rituals, images, and stories that the Holy People had given to the Navajo for just this purpose. The ceremony was successful. Sarah’s symptoms were relieved, her energy restored, her anxiety disappeared, and she continued to function in her role as matriarch for several months until she drifted into a long sleep and died. 

To explore the nature of Sarah’s healing, I have to explain a little more about Navajo medical beliefs. In traditional Navajo thought, all illness represents disharmony, in essence a snag or gap in the interconnectedness that characterizes the dineh (people), the harmonious Navajo Way. While there are many causes of disharmony (e.g. witchcraft, demon possession, soul loss, taboo violation, and traumatic exposure, as with Sarah Mailcarrier), the goal of treatment is always the same—to restore proper harmony at all levels, from within the patient’s own heart, to his or her relationship to the cosmos.  

The ceremonies, which can last up to nine days, require the patient and family to hire an ha’a’tali and his assistants, and to invite friends and clan members to set aside their other responsibilities and participate in songs, dances, prayers, and other rituals appropriate to the ceremony. Sung by the ha’a’tali these are magnificent narrative poems that tell of the creation of the Navajo people, and how all things were originally placed into their proper order. Likewise, in ceremonial dances, men impersonate Yei Be Chai, intermediaries between the Holy People (whom we might call “gods”) and the Earth Surface People (us), and channel their healing power.  

However, the dineh have never rejected Western medicine. Instead, they have integrated Western physicians, clinics, and hospitals into their overall worldview, considering them synergistic with, rather than antagonistic to, traditional ceremonies. The dineh believe that Western health care has simply added a different set of stories and a different network of ceremonies (e.g. clinic visits, x-rays, penicillin shots, arthritis pills) onto their already existing—and far more important—traditional healing practices. The Navajo were quick to observe that bilighani treatments were effective in alleviating outward manifestations, or what we would call symptoms, of disharmony, but they also maintained that such treatments had no influence on the underlying existential disorder. In other words, penicillin shots and arthritis pills are only symptomatic treatments. While bilighani methods could make the fever or rash or cough disappear, at least for a time, the fundamental issue of disharmony would remain. Why me? What does this illness mean in my life? How does this illness reflect my relationship to the cosmos? These questions could only be answered with reference, for example, to the story of Spider Woman, or the Hero Twins, or other narratives of Navajo cosmogony.  

Returning to Sarah Mailcarrier, it appears that by undergoing a Night Way Sing, she experienced a dramatic improvement in her quality of life. From a Western perspective, why might this be the case? First, the lengthy ceremony provided extensive and intense social support, represented by the participation of her extended family and friends, their contributions of time and money³, and overall solidarity. An extensive body of research indicates that high level of social support and prosocial behavior are associated with longer life, less morbidity, less disability, and greater satisfaction. Second, Sings are integral components of religious practice. For a person like Sarah Mailcarrier, religious belief (in the Western sense of the term) and cultural practices were inextricable. Once again, considerable research indicates that frequency and intensity of religious practice is associated with the same positive outcomes. Third, the ritual chants, vivid poetic images, storytelling, sandpainting, and dancing of the Night Way embody a belief system that generates positive expectations—and restores coherence to the patient’s life.⁴  

These components—social support, core beliefs, and positive expectations—all rely on language and communication. Empathy, the human ability to “intuit” what another person is thinking or feeling⁵, is a more basic neurological property than language, but without language humans could not have created the rich symbolic world in which we live. In the 1980s the psychiatrist Donald Sandler distinguished between Navajo symbolic healing, based on an integrated cultural narrative, including symbol and ritual; and scientific healing, which he believed could be clearly distinguished from the latter and which relies solely on specific instrumental effects of drugs, surgery, and so forth.⁶ Like Sandler, today’s physicians are quite willing to make allowances for the beliefs of patients from other cultures, but at the same time they cling to the belief that scientific medicine transcends culture and our effectiveness as healers is solely, or almost solely, explained by the instrumental effects of drugs and procedures. Thus, there is a widespread belief that scientific medicine is, as a system of curing disease, intrinsically culture-free. Antibiotics kill bacteria whether the patient is a middle-class American or an Amazonian Indian. Culture may enter into the picture for the Indian, e.g. because of his mistaken beliefs about illness, but has no effect on the American, whose beliefs (whatever they are) are medically invisible.  

From Placebo Effect to Contextual Healing 

For over 200 years Western physicians have been explicitly aware of the so-called placebo effect, but for most of that time have considered it a minor and somewhat disreputable factor on the medical scene. The first person to recognize and demonstrate the placebo effect was English physician John Haygarth in 1799, who was curious about the purported benefit a popular medical treatment of his time called “Perkins tractors,” metal pointers supposedly able to ‘draw out’ disease from the patient’s body. They were sold at the extremely high price of five guineas, and Haygarth set out to show that the high cost was unnecessary. He did this by comparing the beneficial results obtained by using dummy wooden tractors with those obtained with a set of allegedly active metal tractors. There was no difference. He published his findings in a book called On the Imagination as a Cause & as a Cure of Disorders of the Body.⁷ Subsequently, the term placebo (“I will please”) was coined to mean, as in this 1811 definition, “an epithet given to any medicine adopted more to please than to benefit the patient.” 

The modern understanding of the power of placebo intervention probably originated with Henry K. Beecher‘s 1955 classic paper, “The Powerful Placebo,” in which he described his experience as a medic during World War II⁸ After running out of pain-killing morphine, in desperation he replaced it with a simple saline solution, while continuing to tell the wounded soldiers that the injection was morphine. He often found that saline appeared to be almost as effective as morphine in relieving his patients’ pain and anxiety. Despite this dramatic demonstration, the orthodoxy surrounding placebo effects for the next several decades came to include three major components:  

• A focus on the specific intervention as its cause, i.e. the pill or the procedure itself “carried” or “transmitted” the placebo effect. 

• Importance of patient vulnerability, i.e. only suggestible persons were placebo-responders. 

• Miscommunication, i.e. the patient must deceived, directly or indirectly, into believing that he or she was receiving an “active” treatment.  

However, research in the last 30 years has completely exploded this orthodoxy and replaced it with a much more complex understanding that sheds light, for example, on the power of traditional medical systems, like the Navajo, that rely on poetry, narrative, and ritual to heal. To quote Franklin Miller and Ted Kaptchuk, two of today’s most prominent investigators in the field: “To promote a more accurate understanding of the elusive and confusing phenomenon known as the placebo effect, we suggest that it should be reconceptualized as contextual healing… Factors that may play a role in contextual healing include the environment of the clinical setting, cognitive and affective communication of clinicians, and the ritual of administering treatment.”⁹ Elsewhere, Kaptchuk added, “Research also suggests that (narrative and) ritual healing not only represents changes in affect, self-awareness, and self-appraisal of behavioral capacities, but involves modulations of symptoms through neurobiological mechanisms.”¹⁰  

Contextual healing, as the term implies, occurs in the context of expectations that arise from a network of beliefs. Moerman and Jonas, highlighting the fact that context can communicate therapeutic meaning to the patient, prefer using the term “meaning response.”¹¹ In some cases these beliefs may be based on past experience, but isolated from, or not intimately connected to, deeply meaningful worldviews (e.g. that penicillin cures a sore throat). In other cases they may closely connected to robust belief systems about the nature and origin of illness and healing (e.g. the Navajo Night Way). The latter are obviously more important than the former. The net valence of one’s beliefs determines the meaning of any medical interaction or treatment and, therefore, one’s expectations of its effect. Language, communication, empathy, narrative, and ritual determine the healing context. The universality of contextual effects on symptom relief has been demonstrated convincingly in neurobiological studies, especially those dealing with pain reduction. For example, on fMRI “placebo” treatment reduces activation of pain-related areas of the brain, e.g. the dorsolateral pre-frontal cortex.^{12, 13}  

Contemporary research on contextual healing has also revealed a number of unexpected features that are inconsistent with the earlier orthodoxy regarding placebo effects. For example, 

• Placebo effectiveness does not require deception; patients may report relief of symptoms even when told they are receiving placebo treatment.¹⁴ 

• There may be a link between genetic variants in the dopamine, opioid, serotonin, and endocannabinoid pathways in the brain and placebo responsiveness.¹⁵ 

• Placebo effects (as well as nocebo, or harmful effects) can exist in routine clinical practice, even if no “intervention” is given.^{16, 17} 

• Placebo response is greater when observed in clinical practice than when measured in randomized clinical trials.^{8, 19}  

This last feature requires some clarification. This is precisely the opposite of specific medication effects, which are almost always more prominent in clinical trials than in routine practice because the populations in trials are highly homogenized (e.g. limited age range, selected to exclude co-morbidities), adhere to highly structured protocols (e.g. frequent follow-up, expert clinicians. methods to insure, or at least measure, compliance) and include only highly motivated subjects. These conditions are ideal for demonstrating the drug’s maximal specific benefit (efficacy), while at the same time somewhat less ideal for showing contextual healing power, since individual variation and personal narrative are minimized. The specify potency of a drug tends to be less in ordinary clinical practice (effectiveness) where there are a mixture of patients with different ages, backgrounds, comorbidities, and levels of compliance. However, the latter less-than-standardized conditions are likely to enhance the power of contextual healing. For example, “It seems likely that the effectiveness of placebo for pain relief in osteoarthritis can be considerably larger than its efficacy. The artificial conditions of a clinical trial constrain the extent to which context effects…” can be manifested.²⁰ 

Can Language Spoken in Context Cure Disease? 

Given that contextual or narrative healing may be a powerful force in relieving symptoms and improving quality of life, can it ever cure chronic or progressive disease? It is unlikely that Sarah Mailcarrier’s Night Way ceremony damaged her cancer cells or had any influence on their progress. However, it seems clear that narrative healing may in many cases “cure” at least some cases of major depression, generalized anxiety, post-traumatic stress syndrome, substance abuse, and perhaps even schizophrenia. Since these disorders are all characterized by abnormal concentrations or function of neurotransmitters, it is safe to say that contextual healing influences brain chemistry. Likewise, fMRI studies have shown that placebo treatments alter brain function. For example, placebo treatment in Parkinson’s disease may result in demonstrable changes in imaging, primarily resulting from increased dopamine release in certain areas of the basal ganglia.²¹ These changes may be associated with improvements in patient function. Likewise, placebo has also been shown to modulate physiological processes, like lowering blood sugar in diabetics and treatment enhancing immune responses, which may be related to neurophysiology in complex ways. ^{22, 23} 

There is a long history of rare, unexplained, but yet well-documented, cures in medicine. As medical knowledge has increased, the number of such inexplicable or “miracle” cures has diminished. Nonetheless, instances of the disappearance of widely metastatic cancer, or the resolution of aggressive autoimmune disease, do occur. Religious persons attribute these unexplained cures to supernatural intervention. Jacalyn Duffin’s 2009 book Medical Miracles: Doctors, Saints and Healing in the Modern World describes her investigation in the Vatican archives of 1400 cases of miracle cures that were cited as evidence in canonization proceedings between 1588 and 1999.²⁴ Of these, 503 cases occurred in the 20^th century and 220 of them between 1975 and 1999, the final year of her study. Most in the 1975-1999 group were extremely well-documented. 20^th century cures included 41 cases of cancer or leukemia, 109 neurological diseases (e.g. multiple sclerosis, myasthenia gravis, Parkinson’s disease), and 89 obvious orthopedic conditions. The unifying factor was that every “miracle” was associated with narrative and ritual. Prayer to Jesus, Mary, or another person, i.e. the candidate for sainthood, took place in various contexts, solitary or communal narrative associated with Masses, novenas, relics, monuments, tombs, etc. These features are all analogous to Navajo healing ceremonies. The same sort of analysis has been applied to “miracle” cures at Lourdes, a pilgrimage site in France, with similar results: a relatively small number of thoroughly documented and inexplicable cures among many thousands of claims.²⁵ 

A Note on Nocebo 

Traditional cultures also recognize the power of language to harm, as well as heal. This includes spells, hexes, curses, and similar verbal insults that produce harmful effects on the person to whom they are directed. Since the phenomenon of “Voodoo death” was described by Cannon in 1942²⁶, various other syndromes of illness and death based on witchcraft and curses were re-evaluated or newly described have been reported; for example, “bone-pointing” (kurdaitcha) in Australia and “breaking tapu” in New Zealand. Among Aboriginal people an individual targeted by bone pointing may die within 24 hours or may decline inexorably over a period of days. ²⁷ Such a curse can only be reversed by the intervention of an appropriate sorcerer. Among the Navajo, many serious illnesses are caused by curses that lead to “soul loss” or “possession.”  

Likewise, in Western medicine the words of physicians or other health care professionals, and the context in which they are spoken, may actually increase a patient’s symptoms, anxiety, and suffering. The eminent internist Eric Cassell, paraphrasing an old childhood chant, taught “Sticks and stones may break your bones, but a word can kill you.” (Personal communication) There is no room here to discuss nocebo-inducing language in medical practice, which is analyzed in detail in chapter 13 of Coulehan and Block.^{28, 29} 

Conclusion 

In this essay I make the claim that contextual healing (aka the placebo effect) plays a major role in medical practice and that language, either spoken verbally, or used internally to represent beliefs and personal meanings, is the carrier or operative agent of contextual healing. In most circumstances contextual healing has a limited, but clinically significant, range of effects. The clinician by employing “skillful means” (to use a Buddhist expression) can promote and enhance contextual healing in the clinical setting.^{20, 31} Navajo medicine is an example of a traditional medical system built almost entirely on exploiting the vast resources available to contextual healing. To a greater or lesser extent, Curanderismo, Vodun, homeopathy, Christian Science, and many other approaches to the treatment of illness are based on contextual healing. The upper limit of this healing power is normally modest, but under certain circumstances for certain people it may be quite spectacular, as in presumptive miracle cures.  

Notes 

1. Navajo Night Way Song, https://www.lindavallejo.com/wp-content/uploads/2018/12/Chants-Prayers-Poems-2011-2.pdf, accessed on 3 December 2025. 
2. Coulehan J. May I Walk in Beauty. Humane Medicine, 1992; 8: 65-69. 
3. Kaptchuk TJ. Placebo studies and ritual theory: a comparative analysis of Navajo, acupuncture and biomedical healing. Phil Trans R Soc B. 2011; 366: 1849-1858 
4. By “intuit” I mean the development of a theory of mind (i.e. others have minds just like me). Primates and perhaps some other mammals have an analogous ability, but presumably without a symbolic language. 
5. A Sing is expensive. The patient’s family must hire an ha’a’tali and his assistants and also provide food and drink for a large number of participants and attendees. Some participants must also take time off from their jobs or other pursuits for several days. 
6. Haygarth J MD. On the Imagination as a Cause & as a Cure of Disorders of the Body, Bath; R. Cruttwell, 1801. 
7. Sandler D. Navaho Symbols of Healing. New York, Harcourt Brace Jovanovich, 1979, pp. 265-273.  
8. Beecher HK. The powerful placebo. JAMA. 1955;159(17):1602-1606 
9. Miller FG, Kaptchuk TJ. The power of context: reconceptualizing the placebo effect. JRSM. 2008; 101: 222-225, p. 223. 
10. Kaptchuk TJ. Placebo studies and ritual theory: a comparative analysis of Navajo, acupuncture and biomedical healing. Phil Trans R Soc B Biol Sci. 2011; 366: 1849-1858, p. 1849. 
11. Moerman DE, Jonas WB. Deconstructing the placebo effect and finding the meaning response. Ann Intern Med 2002; 471-476. 
12. Brody H, Miller FG. Lessons from recent research about the placebo effect—from art to science. JAMA 2011; 306 (23): 2612-2613 
13. Colagiuri B, Schenk LA, Kessler MD, Dorsey SG, Colloca L. The placebo effect: From concepts to genes. Neuroscience. 2015; 307: 171-190 
14. Pecina M, Zubieta JK. Molecular mechanisms of placebo responses in humans. Mol Psychiatry. 2015; 20: 416-423 
15. Miller FG, Coilloca L, Kaptchuk TJ. The placebo effect: illness and interpersonal healing. Perspect Biol Med. 2009; 52: 518 
16. Stub T, Foss N, Liodden I. “Placebo effect is probably what we refer to as patient healing power”: a qualitative pilot study examining how Norwegian complementary therapists reflect on their practice, BMC Complementary and Alternative Med. 2017; 17:262 
17. Benedetti F, Pollo A, Lopiana L, Lanotte M, Vighetti S, Rainero I. Conscious expectation and unconscious conditioning in analgesic, motor, and hormonal placebo/nocebo responses. J Neurosci. 2003; 23: 4315-4323 
18. Dieppe P, Goldingay S, Greville-Harris M. The power and value of placebo and nocebo in painful osteoarthritis. Osteoarthritis and Cartilage. 2016; 24:1850-1857 
19. Haake M, Muller HH, Schade-Brittinger C et al. German acupuncture trials (GERAC) for chronic low back pain: randomized, multicenter, blinded, parallel-group trial with 3 groups. Arch Intern Med. 2007; 167: 1892-1898 
20. Dieppe et al, p. 1852. 
21. Fuente-Fernandez R, Ruth TJ, Sossi V, Schulzer M, Calne DB, Stoessl AJ, Expectation and Dopamine Release: Mechanism of the Placebo Effect in Parkinson’s Disease. Science. 2001; 293: 1164-1166. 
22. Skvortsova A, Veldhuijzen DS, van Dillen LF, Zech H, Derkson SM, Sars RH, Meijer OC, Pijl H, Evers AWM. Influencing the Insulin System by Placebo Effects in Patients With Diabetes Type 2 and Healthy Controls: A Randomized Controlled Trial. Psychosomatic Medicine. 2023; 85: 551-560 
23. Smits RM et al. The role of placebo effects in immune-related conditions: mechanisms and clinical considerations. Expert Rev Clin Immunol. 2018; 14(9): 761-770. 
24. Duffin J. Medical Miracles. Doctors, Saints, and Healing in the Modern World. New York, Oxford University Press, 2009. 
25. François B, Sternberg EM, Fee E. The Lourdes medical cures revisited. J Hist Med Allied Sci. 2014 Jan;69(1):135-62.  
26. Cannon WB. “Voodoo” death. American Anthropologist, 1942; 44: 169-181. Reprinted in Am J Public Health. 2002; 92 (10): 1593-1596. 
27. Spencer, Baldwin; Gillen, F.J. Native Tribes of Central Australia. Cambridge University Press, 2010 [1899], pp. 476–477. 
28. Coulehan J, Block M. The Medical Interview. Mastering Skills for Clinical Practice. Philadelphia, F.A. Davis Company, 5^th edition, 2006, pp. 21-44 and 249-278.  
29. Hansen E, Zech N. Nocebo effects and negative suggestions in daily clinical practice – forms, impact and approaches to avoid them. Front Pharmacol. 2019 Feb 13; 10:77. 
30. Coulehan J, Clary P. Healing the healer: Poetry in Palliative Care, J Palliative Medicine, 2005; 8: 382-389. 
31. Blasini M, Peiris N, Wright T, Colloca L The role of patient-practitioner relationships in placebo and nocebo phenomena. Int Rev Neurobiol. 2018; 139:211-231.  

Web image created by Medhum.org

Five years into writing about her mother’s slow decline from a respiratory illness, Joanne Jacobson was diagnosed with a rare, life-threatening blood disease. That discovery dissolved the illusion that she and her mother had separate fates. “How could I continue writing about my mother as though I were observing her from outside the circle of Illness?” Jacobson asks (27). She can’t. And Every Last Breath becomes, as its subtitle discloses, “A Memoir of Two Illnesses.” Doubling its concern, Jacobson’s memoir in essays becomes a richer, more urgent, and ironic revision of her original project.  

With writerly attentiveness, perceptive intelligence, and some impatience, the four opening essays witness the negotiations that Florence Jacobson makes with her body, her environment, and her psyche. From a distanced perspective, Jacobson wonders at her mother’s courage and stubborn animal will to go on. Her mother’s slow pace and reluctance to let go—of her possessions, her habits, her life—initially frustrate and puzzle Jacobson. She even expresses impatience with the constant sound of her mother’s oxygen pump filling the apartment, the inconvenient bulk of the oxygen canister, the tangles of tubing connecting the machine with her mother’s nostrils.  

As Jacobson’s diagnosis closes the distance she perceived between herself and her mother, it ignites the memoir’s transformative insight. It’s first articulated at the end of the essay titled “Mirror Writing” and it sustains the rest of the memoir. Realizing that her mother might outlive her, Jacobson writes: “. . . I can no longer pretend that the ragged approach of death is likely to be smoothed by nature’s grace, or by the natural order. So long as I believed I was writing about my mother, I was able to hold mortality at a distance . . . Now in the mirror of my mother’s aging face I see myself” (29). In “Dead Reckoning,” when Jacobson learns that her blood is starved for oxygen, she hears her “own lungs fall into the thrumming motor’s pulse” of her mother’s respirator. Revising her response to the technology, she writes that it is “the sound of death being pushed mechanically away that is audible to me now—steadily asserting its nearness . . .” (63-4). Jacobson’s descriptions of her hospitalizations and treatments (“Written in Blood,” “If My Disease Were an Animal”) sharply observe her new understanding of herself and the “call to the imagination” that her experience issues (59). Jacobson’s elegant and vulnerable rendering of her efforts to survive pain, uncertainty, and terrifying treatments register her courage and will to go on.  

The final essays bring together the shared destinies of mother and daughter. Jacobson thinks of their relationship as “invisibly entwined, cellular,” as she recalls that mothers’ bodies can absorb the fetuses’ cells (88). In “Book of Names,” Jacobson’s closing essay, she and her mother recite the names in Florence’s heavily edited address book, tracking the alterations in the lives she’s shared. The recitation invokes the lists in Genesis. Begotten. Gone.  

Every Last Breath should be read. Its profound and startling reflections on mortality are lyrical, fierce, and deeply felt. At times readers take extravagantly metaphorical flights of the imagination. At times we’re immersed in revelatory scientific facts about the natural world and our human biology. This slender book melts other boundaries as well: between caregiver and patient, mother and daughter, self and other, personal and universal. It simultaneously challenges literary classifications, blending poetry, essay, and memoir. Read separately or together—either way can be satisfying—Jacobson’s brilliant essays refuse to let us ignore our shared vulnerability or the unpredictability of living in a body, as Jacobson once naively thought she could. 

Every Last Breath–A Memoir of Two Illnesses
Joanne Jacobson 
The University of Utah Press, 2020; 114 pages 
https://uofupress.com/books/every-last-breath/

A previous version of this review was published in the NYU Literature, Arts, and Medicine Database. 
Web image created by Medhum.org

The Eye in the Door, the second in the trilogy, turns its attention to the Home Front, and more specifically describes the rampant paranoia during the war, as the government targets two groups:  homosexuals and “conchies,” or conscientious objectors.  While it too is tethered to historical fact, it is more of a fictional narrative concentrating on the state-sponsored witch-hunt, refracted through the story of Billy Prior, a patient of Dr. Rivers.  Billy is bisexual; he also grew up with childhood friends who became pacifists and objectors, and who may or may not have been involved in a plot to assassinate the Prime Minister, and so he moves in both of these marginalized and persecuted worlds.  He also has fallen in love with a woman whom he wants to marry.  During his ongoing treatment of Billy, Rivers confronts his own repressed childhood memories.   

The Regeneration Trilogy has much to recommend it in considering works of literature in the area of medical humanities.  First—and obviously—it is about the psychological damage suffered by young men pressed into military service during wartime, and the way in which medicine approaches their resultant illness with the tools it has at hand.  Each one of these soldiers has a story, each one has a trauma, and there are no pharmacological options. Much like Freud (a contemporary whose work was well-known to him), Rivers felt that the way to treat the shell-shocked soldiers was a “talking cure,” making the traumatic events unrepressed and having the patients recognize and address them.  The stories of the soldiers’ treatments are engaging, Rivers’ warmth and compassion for his charges is unmistakable, and the nature of physician-patient interaction during treatment is explored.   

Barker also poses questions about gender; more specifically, about the nature of manhood and the role of women in a male-dominated society turned upside down by a cataclysm.  Being a man in England during the war means being in uniform and preferably fighting in France; the conchies and the gay men are seen by many, including many women, as being “less than” men, and in their otherness, as subversive.  Women, for their part, have had to step up and assume the roles in the workforce that men have vacated to go off to fight.   It is supposedly the love of their fellow men that allows the soldiers to fight as a unit, to want to enlist and to want to re-up after they are wounded, and this comradeship is trumpeted by those in command.  But it is crucial that everyone understand that this must be the right kind of love; the wrong kind of love is ferreted out and made example of. 

There are many paradoxes, and many instances of doubling or of opposites, in the novels.  Rivers wants to cure his patients, although curing them will render them fit to be sent back to combat and likely be killed.  Several bisexual men lead bifurcated lives.  And underlying all of it is a society rigidly divided along class lines, with the WC’s—the working classes—distinguished not only by their living and working conditions but also by the idiomatic speech put into their mouths by the author.   The war may be in some ways a great “we’re all in this together” moment, but it can’t erase class distinctions.   

It is worth noting that Barker’s style can range over to the gritty and realistic, as well as the graphic, whether describing the events occurring on a battlefield in Picardy or in a bedroom (or back alley) in London. The writing style is crisp, and the narrative moves along nicely.  The author’s characterizations are on point, especially William Rivers and Billy Prior.  Barker has a great feel for language, although some of the words and expressions several of the characters use are distinctly British and may be unfamiliar to American ears.  She conveys an England—or at least, a segment of England—tired of war, tired of being bombed, often living hand to mouth in cold water flats with faded wallpaper and trying gamely to carry on despite being ground down. 

And underlying it all, The Great War—its idealization, its senselessness.  The three volumes of this trilogy are beautifully written, hold the attention, and move quickly, and its relatively spare language has a lot to say. 

The Eye in the Door
Pat Barker 
Dutton: 1994, 288 pages 

Photo of Chester from  The Cleveland Museum of Art 

For more than a decade, I kept running into the Emperor of All Maladies at various bookstores, book shops, and libraries. Siddhartha Mukherjee’s Pulitzer Prize winning biography of cancer would glare at me from its position on the bookshelf, daring me to read it, but each time I saw it, I would mull over the idea of reading a 450 page history of medicine book, shake my head, and move on to something lighter and less strenuous. Mostly, tired from my day job as a family doctor, I just wanted to read something less medical.

Last fall, it happened yet again. I ran into the Emperor of all Maladies once more, this time at my local library’s annual used book sale. For the princely sum of $1, I picked up the book, flipped through it, and thought, why not?

What I discovered was a book that was all that I had expected it to be, and more. Yes, it’s a long, exhaustive read. Yes, it contains long sections of exposition, explaining the details of how protein kinases and mRNA work on a molecular level. But it’s also eye opening and moving and manages to make the connection between what happened in hospitals and clinics a hundred years ago with the state of not just modern oncology, but modern medicine as a whole.

Last fall, I joined MedHum and before long, we realized MedHum needed a podcast. But what would we talk about? And that’s when I realized that Mukherjee’s book, with its vast scope, and comprehensiveness would be the perfect starting point for the show.

Then I thought, I needed to convince someone to read this book with me. And who better than my literary podcast buddy, Mr. Luki Danukarjanto. Luki is a career coach, writer and the founder of Focus Inspired, a service dedicated to helping people achieve meaningful career change. He also lives in Toronto.We’ve been talking about books on the W5H Book Club podcast together for the last several years. Why not read about medical humanities?

The result is two dudes who love to read talking about a great book.

Welcome to the premiere episode of Apollo On Call. Enjoy.

Dr. David Hsu

Transcript from this episode

Mrs. Lin is a fifty-five-year-old woman who has lived alone in Canada for many years while her husband lives back in China. Her two sons are both working and out of the house. Last week, she discovered a new breast lump while showering. A few days later, she’s in my clinic to get the lump checked. As her family doctor, I order a mammogram and an ultrasound. When the results of these tests come back a few days later, the report indicates that the findings are suspicious for malignancy and a biopsy is necessary. 

Mrs. Lin returns to the clinic and I relay the information to her. I try not to mention the word “cancer” to her, but it hangs between us, powerful even if it remains unsaid. I urge her not to jump to worst case scenarios, but we both know that one way or the other, this is life altering news. I promise to order a referral to the breast diagnostic clinic at the community hospital nearby and that the breast centre will reach out to her in the next week or two. 

Later in the week, I receive a fax from the breast clinic. They’ve been trying to reach my patient by phone but with no success. Do we have another way of contacting her? 

I instruct my office staff to try to reach the patient. They call repeatedly for a few days. The breast clinic appointment is scuttled but I’m not actually worried. I’ve seen this pattern many times before. I am certain the patient has already flown the coop. 

A few days later, my hunch is proven right. My nurse manages to reach one of Mrs. Lin’s sons. His mother is safely back in China, seeking medical attention there. They’ll call us when she returns sometime next year. 

When my father boarded a plane in Taiwan in 1967 to come to Canada on a one-way ticket for graduate school, my grandmother saw him off at the airport. She gave him $1000 and said, “I’ll see you in about ten years.” 

She wasn’t far off. In fact, he didn’t return to Taiwan until 1974, for his wedding. 

That was what being a Chinese-Canadian immigrant was like back in those days. A journey to the other side of the world was truly a journey into an unknown abyss. Letters marked “airmail” with the blue and red checkered envelope edges took weeks to circumnavigate the globe. If my father wanted to call his parents, he’d reserve the call for special occasions like Chinese New Year because long distance rates were exorbitant. And even then, he’d be careful to limit the call to one minute and fifty seconds because exceeding the two-minute mark meant paying unnecessary fees. 

Immigrating was essentially a one-way trip. Immigrants like my father rarely considered the prospect of flying back home because it was something most of them simply couldn’t afford. There were only two acceptable occasions to fly home: your own wedding or a death in the family. 

The journey for today’s Chinese-Canadian immigrants is different. Not only can they communicate easily with those back home using apps like WhatsApp, WeChat and Line on an hourly basis, but based on my observation of my Chinese Canadian immigrant patients, even those who struggle financially, seem to have a reserve fund that they can dip into and use to return to China on a moment’s notice. Home is never more than a one-day airplane flight away. 

And people fly back for all manner of reasons now: family illnesses, Chinese New Year, summer vacations, and most definitely, for expediting medical investigations. 

The fluidity with which patients move back and forth speaks to a difference in what motivates immigrants to come to Canada. When my parents’ generation left China or Taiwan or Hong Kong, often it was to trade a future bleak of possibilities for a possibly prosperous future. But for many of today’s Chinese immigrants, it’s a trade of one hopeful future, for possibly, a slightly better one, but with the option to go back if this future in the West doesn’t work out. 

Health care has become part of this back-and-forth fluidity. It used to be that the health care trade off would have been clear–Canadian health care was more advanced than that in China in the sixties and seventies. But that’s not entirely true anymore, and today’s immigrants arrive with a great deal more reticence about our health care system. 

Health care always presents unique challenges to an immigrant population. Illnesses imply a degree of immediacy and urgency. They play out on their own timetables – they don’t wait for people to become comfortable with the language or culture of a place before occurring. 

So the new immigrant is forced to face the health challenges of regular life—acute illnesses, chronic diseases, bodily injuries, babies being born, and even the occasional life-threatening-situation without the social support structure that they would have had back home. All this is part of the bargain that the new immigrant strikes with their adopted country. And so they pray that nothing major will befall them, but when something invariably does, what do they do? 

In the previous generations, immigrants here had little recourse but to seek out solutions in the Canadian health care system. Whether their English was up to snuff or not, they were forced to navigate the system here. Many Chinese immigrants like my parents flocked to Chinese-speaking doctors like me in the hope that at least less would be lost in translation if they found a Chinese person holding the stethoscope. 

The modern immigrant though, has the luxury of straddling the line between the Canadian and Chinese health care systems, keeping one foot in China’s health care system and another foot in Canada’s. 

Unhappy with the wait times for elective knee surgery in Ontario? No problem. A doctor in Taiwan or Hong Kong will have you on the table in the OR in a few weeks, not months. 

New discovery of lymphoma? No need to wait for your family doctor to refer you to an oncology clinic and for that clinic to send you for imaging before finally making a decision on treatment—a process that can easily span into months. If you fly back to China, you can walk into a specialty clinic the next day, see a doctor by lunch time and have imaging and an oncology plan done by the end of the week. 

When it comes to China, the western world has a tendency to see things in stark black and white terms: e.g., freedom is good and communism is bad. As a Chinese Canadian physician, I find that this type of thinking carries over to our view of the health care system. Medical students in Canada, are taught that the Canadian health care system is a virtuous, humane social experiment, one of the country’s proudest achievements. It’s drummed into us that it delivers world-class care to the majority of its people. And we’re proud to be trained in it. Sure, it has its problems, but nothing’s perfect. 

There is a hidden side to this curriculum though. If we’re world class here, what about health care systems in other places? What about Africa? What about South America? What about China? 

Perhaps unintentionally, we’re taught to look down on the systems of other countries. We use words like ”developing“ and “evolving” to describe health care systems in these places. But in private, we often shake our heads in exasperation and use far worse language than that. 

These stereotypes were only reinforced when I started practicing medicine about fifteen years ago. The requests of my Chinese patients, often rooted in their own experiences with the health care systems they had left behind, drove me batty on a daily basis. 

I’d try to explain to my patients that, “Yes, that might be the case there. But you don’t really need any of those things.” But it’s hard to convince someone that everything they’ve accepted as truth may not be correct. 

The worse complaint was always about the wait times. This was one that I could not refute. It’s well-known that wait times for medical procedures in Canada are criminally lengthy. But whereas my Canadian patients had nowhere else to go and would just vent to me about the breaking down of our country’s beloved health care system, or try to drive a few hours to Buffalo to get an MRI, my Chinese patients had the luxury of options. They could hop on a plane, land in China or Hong Kong or Taiwan by the end of the week and get whatever they wanted within days, not weeks or months. 

I should point out that the feedback from patients about the Canadian health care system wasn’t always negative when compared to back home. I learned that the fifteen to twenty minutes I allocated to speak to each patient was approximately twelve to eighteen minutes more than they got in the typical Chinese hospital. 

Still, there were many frustrations that I was unprepared for. Patients would return to my clinic armed with reams of paperwork (all in Chinese), documenting checkups and physical exams that they had done overseas: lab tests and CT scans that had no indication for being ordered, medications that they had been prescribed that were not really indicated. 

If modern medicine in the West suffers from an over-reliance on medical imaging and pharmaceuticals at the expense of a more prudent and holistic approach to care, then modern Chinese medicine has become Western medicine’s adopted twin, with all the same problems we have, except with even less sense of restraint and caution. 

Mr. Zhang is a middle aged, Chinese man with diabetes. In China, people routinely retire in their early fifties and one of the perks of retirement is long term health insurance, so even though Mr. Zhang has lived in Canada for almost fifteen years, he still can access Chinese health care whenever he is back home. 

Mr. Zhang isn’t alone in returning home to seek health care. Even those without health insurance often choose to pay out of pocket to access health care in China on a regular basis because the costs aren’t prohibitive 

Because Mr. Zhang travels back and forth between China and Canada on a regular basis (after all winters in Canada are cold), he needs doctors on both sides of the world to help him manage his long-term diabetes. What he’s discovered is that the quality of care in both countries is, for him at least, comparable. The general procedures for diabetes, routine blood testing, and medication adjustments, are similar in both places. But there are some noticeable differences. 

He informs me that in China, the health care system is heavily incentivized by the profit motive. Hospitals make more money if they achieve certain revenue quotas, and this is passed on to the doctors, who in turn pass this mindset down to the patients. 

At the same time, it’s well known to him and all his friends, that in Canada, with a public health care system, cost-cutting is much more of an issue. 

The doctor as gatekeepers of the health care system is sometimes a difficult concept for patients to understand. Doctors in China are not really gatekeepers of the system the way they are in Canada, where doctors spend a great deal of time being instructed on not over-ordering tests. Not all medical investigations are necessary. Extra tests beget extra costs and may engender unnecessary anxiety and have deleterious consequences for the patient-just think about the patient who worries about a lung nodule that will never cause them problems once it’s been spotted on an unnecessary chest X-ray. These are hard lessons that even medical practitioners in the West struggle with at times. For my patients from China, this concept is irrelevant. In a privatized system where patients can pay for what they want, getting an unnecessary MRI is no different than spending money on a fancier car or an extra helping of dessert: nobody really needs it, but if they can afford it, then why not? 

So if I try to explain to my patients why I don’t think they need that MRI they really want, they think I am just trying to save the government of Canada money. If I am really hard-nosed about it, they just might turn around, get on a plane and have the test done in Shanghai or Taipei by the end of the week. 

In China, if I want an MRI and can afford to pay for one, then who is anyone to stop me from getting what I want? If a cardiologist makes more money for pushing a certain type of stent at a patient, who is going to stop them from recommending it to patients who might do just as well with a less aggressive intervention? 

To be sure, these are problems that exist in many parts of the world, even here. But reviewing the stacks of lab results and CT scans that my patients lug back to Canada from overseas, I can’t help but feel that my patients have stumbled upon the Wild, Wild, West of health care-except it’s in the Far East. 

There is of course a downside when patients straddle two countries for their healthcare. Countless times, I’ve had patients return from overseas after having had a major health calamity. Maybe they had breast cancer diagnosed in China, or a screw placed in their hip after a fall, but now that they’ve returned to Canada, no specialist office will see them.  

Dutifully, the patient brings copies of their hospital notes from China, copies of their CT scans and MRIs, but nobody here is willing to read them because nobody here trusts what the report says. If the documents are written in Chinese, Canadian doctors usually can’t read it. Even if they could and wanted to trust it, can they really do so medico-legally? And so it’s the patient that gets left in the lurch.  

In the end, armed with a Chinese-Canadian dictionary in my early years in practise, or more recently Google translate, I’ve learned to muddle through. With my admin staff translating the documents for me, I can usually piece together what procedure a patient has had done overseas. Then we try to match them with the appropriate follow up here, often repeating the testing and imaging so that patients can access care here. 

But it’s getting better. In my early years, I couldn’t find any oncology clinics willing to follow my patients who had started their chemotherapy overseas. Many of these patients flew all the way here to use their hard-won Ontario health care card, only to have to fly back home shortly thereafter when they realized they weren’t going to receive timely care in Canada. These days, I’ve seen more care handoffs take place here smoothly. Truly, the health care world is becoming a little friendlier to immigrants. 

It used to drive me crazy when my patients sought out health care overseas. In medical school, we’re taught a very idealized version of medical care, something akin to the traditional country doctor’s life straight out of the 19th century. A patient feels unwell. They seek out a local physician. The physician solves the problem or directs them to someone else who can. The problem is solved, and life goes on. 

But in real life, I saw that patients didn’t always stay in one place. Sometimes they asked me for help first. Then they’d go overseas. At other times, they came back from Asia and needed my help deciphering what had happened to them there. And back and forth they went. 

Sometimes I’d get exasperated that they were receiving substandard care overseas. At other times, I’d gain an appreciation that they really could get better, faster treatment for certain things in China that in Canada would have taken ages. In time, I developed a grudging respect for health care in China. 

As I worked with patients who were navigating these two systems simultaneously, I felt myself drawn into a curious, political dilemma. Which health care system is better? 

Sometimes patients would pull me aside and ask me what they should do, fly back to China and seek urgent care or wait a bit longer to see their specialist here in Canada? 

The issues were always some variation of the same theme, a weighing of trade-offs: comfort with the language, wait times, medical expertise, as well as the family support system, all bundled into one massive equation that boiled down to a simple binary question: China or Canada? 

I’ve found my own stance on the issue change over time. When I first graduated from medical school, armed with all my pro-Western biases, the answer was almost certainly Canada. 

But in recent years, I’ve watched medicine advance in China from afar, through what my patients tell me, and through the medical records and histories that they bring back to me. Perhaps there’s still a lot of overkill in investigations on the other side of the ocean, but often the quality of medicine isn’t that different from what it is here. And it’s almost certainly faster. And if you can pay for quicker care, why not? Moreover, many of these Chinese immigrants have family support networks back home that simply don’t exist here. For them to return home for their care simply makes rational sense. Nothing reminds someone of how foreign they are as being in a cold, sterile hospital environment where nobody speaks your language. 

More than a year after she departed, Mrs. Lin returns to my clinic. Following a lumpectomy and ten rounds of chemotherapy, the doctors in China have instructed her to remain on estrogen receptor therapy for the next five years. 

Why did she return to China for medical care? Despite living in Canada for more than a decade and having a passable command of the English language, she still felt that for something as serious as this, she wanted to be someplace she could speak her native tongue. Plus, she would have family members there to support her. Left unsaid is that the entire medical procedure in China took days to arrange not weeks as it would have here. 

I refer her to a medical oncologist, who reports back to me that she is overall, in agreement with the patient’s treatment plan. She replaces the patient’s estrogen treatment with an alternative agent that is available in Canada. 

Web photo by Zac Ong 

Additional Chapters from A Chinese City Doctor’s Notebook

When Your Body Isn’t Yours 

01.12.26 787

From Tigers to Otaku

09.16.25 1660

The Happiest Couple

07.28.25 1402

The Things We Don’t Talk About When We Talk About Dying 

05.13.25 1979

One Patient, Two Systems 

02.24.25 2665

It is one thing to read about bipolar disorder in a textbook, and another thing to observe it firsthand. Some of us have friends or family members whom we have seen in the throes of a manic episode. As a psychiatrist, I have witnessed mania at close range literally hundreds of times. But to be an audience member and to experience it in a way that manages to be both educational and entertaining is a rare privilege. And to do so as a multimedia event, fusing theater with visual arts, is surely unique.  

Sam Kissajukian’s one-man show 300 Paintings is a must-see that is currently enjoying a return engagement at the Vineyard Theatre in New York. (It is purely a coincidence that the theater, just off Union Square, is a block away from my former psychiatric office of eighteen years.)  

Kissajukian is an Australian stand-up comic. In 2021, during the pandemic, he experienced a five-month bipolar manic episode. During that time, despite having no previous background in visual arts, he decided to become a painter. Moving into a warehouse, he began to paint. He barely slept, frequently turning out multiple works a day. By the end of the episode he had created three hundred paintings, documenting his mental state.  

Kinssajukian has created the show he calls 300 Paintings as the culmination of his personal and artistic journey. The show has won numerous awards, including Best Comedy at Sydney Fringe 2022 and 2023, and the Mental Health Awareness Award at Adelaide Fringe 2024. It has played at the Edinburgh Fringe Festival, and it first came to the Vineyard last fall. He has also had several exhibitions of his paintings, and has come out as a strong advocate for mental health awareness. 

While 300 Paintings calls on the author’s experience as a comic, it is no mere stand-up routine. At 80 minutes it has the dimension and scope of a play. There are serious undertones, yet there are many undoubtedly funny parts: We hear how at his most grandiose Kinssajukian thinks of himself as a “Pisscasso” who goes through a blue period in days, rather than years. At another point he describes how he affected a beret. Funny or serious, he is always charming and engaging, and he breaks it up by showing projections of his work.  

There are times when the dialogue takes on the rapid, pressured speech of a person who is manic, and his thought process shows the jumping from topic to topic that a psychiatrist refers to as “flight of ideas,” But this feels intentional. At no time do you worry that the performer does not have it under control. And he readily attributes this to his rapid diagnosis and treatment by a psychiatrist.  

At the end of the performance, Kissajukian announces that a curated exhibition of his paintings is on view in the lobby, and that he will be available to meet the audience.  

Two Paintings by Kissajukian

Podcast

Web image provided by Sam Kissajukian

The phenomenon sometimes referred to as “baby blues,” a mild transient state affecting as many as 80% of new mothers, had been recognized early on. In his influential 1946 book on baby care Dr. Benjamin Spock advised that one could snap out of it by just going “to a movie, or to the beauty parlor, or [getting] yourself a new hat or dress” (p. 29). If a new dress did not do the trick, the implication in that era was that you were a defective woman. In the 1962 edition, Spock still repeated the same advice verbatim. The notion there could be a persistent mood disorder requiring treatment required far longer to catch on. In her book, Moran elucidates some of the factors that rendered it difficult to accept the existence of postpartum depression and explain why persistent advocacy was necessary.  

One such factor involved organized psychiatry. While early editions of the DSM (the Diagnostic and Statistical Manual of Mental Disorders) had proposed psychodynamic causes for mental illnesses, in an attempt to be neutral about their origins the DSM-III did not include postpartum disorders as discrete entities. One implication of this was that there was no code to use to get health insurance to reimburse for medical care. The result, according to James Alexander Hamilton, a psychiatrist who had written the first modern monograph on postpartum mental illness, was that “many thousands of very sick women [were] very badly treated” (p. 67). It took several editions of the DSM until this was addressed. And even in DSM-V, postpartum depression would still be coded as Major Depressive Disorder with peripartum onset.  

Eventually the idea there was something more serious than” baby blues” yet still relatively common took root in the public consciousness. One began to hear about it on television talk shows. Yet these appearances often featured extreme cases such as that of Andrea Yates who had drowned her five children: “Tragedy and insanity got ratings. This still allowed advocates a chance to raise awareness on a massive national platform. But it also made postpartum depression frightening and unclear” (p. 166). It took celebrities such as Brooke Shields to come out about their experiences to change the national conversation. After publishing a memoir about her postpartum depression, in 2005 the actress went on the Today Show where she was criticized by Tom Cruise for using antidepressants. When the public rallied behind Shields, this proved to be a turning point for the movement. 

When national bipartisan legislation was proposed to increase awareness and to fund research for postpartum depression, the issue became a political football. Anti-abortion activists coined a brand new “disorder” they called “post-abortion syndrome” and would not consider supporting one without the other. It was not until the passage of the Affordable Care Act that the MOTHERS act went through, and not even then without the concession to abortion politics.  

If Moran’s book breezes through the science behind postpartum depression somewhat rapidly, its chronicle of an important advocacy movement for women’s health makes it worthwhile, and its extensive use of oral histories within the context of the author’s own history ensures it is an interesting read.  

Blue
Rachel Louise Moran
University of Chicago Press, 2024, 304 pages

Web image by Alexander Grey 

See https://www.postpartum.net/ for information about Postpartum Support International, one of the advocacy groups profiled in Blue.  

It seems as if there is a man named Benjamin Rush who follows me everywhere I go.  He was one of the founding professors at the medical school I attended.   He was on the staff of the hospital where I did my training.  He was one of the initial fellows of the College of Physicians of Philadelphia where I’m now a fellow, and where a medicinal plant garden now bears his name.   He appears on the seal of my professional organization, the American Psychiatric Association.   At one point, apparently, he even came within spitting distance of my future home when he made the famous crossing of the Delaware River along with Washington and the troops. 

But who was this person, really?  That is what I was wondering when I picked up Stephen Fried’s biography Rush. He seems to have known everyone who was anyone, yet Rush himself is one of the least well-known of our country’s Founding Fathers.  It turns out that the answers are complicated. 

Rush has been called the father of American Psychiatry.   When he began to work at Pennsylvania Hospital, he was appalled to discover the “lunatics” chained up and below ground in unheated cells, receiving no treatment.   The public could come in and gape at them for four pence.  Although Rush made wide-ranging contributions to medicine in his long career as a physician (such as guiding Philadelphia through a series of yellow fever epidemics), he returned repeatedly to the problem of the patients in the basement.    

In an era when madness was frequently seen as a moral failing, Rush put forth the theory that it was a disease.  (He believed that about alcoholism too.)  He spoke to the mentally ill like human beings, and when they had delusions, which he called “errors of thinking” (Fried, 2018, p.269), even tried to understand them.  He banished the public from the basement, had heaters installed in the cells, and petitioned the hospital to supply the patients with “exercize and amusements” (Fried, 2018, p.450).  Although Rush wrote prolifically throughout his career, he finally published his magnum opus on the subject just a few months before his death. In Medical Inquiries and Observations, upon the Diseases of the Mind, he sought to bring mental diseases “to the level of all the other diseases of the human body…. Time I hope will do my Opinions justice.  I believe them to be true and calculated to lessen some of the greatest evils of human life.” (Fried,2018, p.469)  

All of this is admirable.  However, the other side of the coin is that some of Rush’s treatment methods were questionable.  True, he was far from being the only physician at the time to use bloodletting for…just about anything and everything.  However, even among his contemporaries, he was known as being so aggressive a bloodletter he was parodied as Doctor Sangrado (a reference to an evil physician in a popular novel who bled patient dry).  He also comes off, at least in Fried’s book, as having as a character flaw an inability to ever admit he was wrong.  So, in defiance of his detractors he persisted in using bloodletting to the end of his career.  And although his recommendations about diet and exercise were indisputably helpful ones, his Tranquilizing Chair and Gyrator (they sound like rides in an amusement park, but probably weren’t very amusing) did not turn out to be.   

In addition to his stubbornness, Rush had a tendency to say things that perhaps he might have thought out more carefully.  He never lived down a foolish criticism he had made of George Washington. He made outrageous pronouncements as a physician based solely on observation.  In what Fried calls “the most spectacularly wrong-headed address of Rush’s career” (Fried, p. 389), he conjectured that the dark skin of black people comes from leprosy. A man of profound contradictions, Rush was an abolitionist who also turns out to have been a slaveowner. While this may not have been unheard of in the 18^th century, it is disturbing today considering some of his statements.  In 2021 The New York Times published an article entitled “Psychiatry Confronts its Racist Past, and Tries to Make Amends” which sees Rush’s leprosy theory as one source of the structural racism in psychiatry that has led to the pathologization of African Americans for hundreds of years.  

Back in 1894, when the American Psychiatric Association unveiled its official seal, it included a likeness of Benjamin Rush’s profile: “The choice of Rush…for the seal reflects his place in history…Rush’s practice of psychiatry was based on bleeding, purging, and the use of the tranquilizer chair and gyrator.  By 1844 these practices were considered erroneous and abandoned.  Rush, however, was the first American to study mental disorder in a systematic manner, and he is considered the father of American Psychiatry.” But today, Rush is evidently no longer considered to be a role model. in 2015, the APA adopted an entirely new logo that did away with Rush altogether, although the organization would “continue to use the seal…for ceremonial purposes and for some internal documents.”  (“American Psychiatric Association,” Wikipedia)  

In conclusion, although we can not necessarily hold historical figures to task for making comments that were considered acceptable at the time, we also need not put them on a pedestal.  Fried’s book Rush depicts its subject as a brilliant man with weaknesses.  The more I read about Rush, the more interesting and complex I find him to be.   

References  
Fried, Stephen. Rush. New York, Broadway Books, 2018 
Warner, Judith. “Psychiatry Confronts its Racist Past, and Tries to Make Amends.” The New York Times, April 30, 2021 (updated May 21, 2021) 
“American Psychiatric Association,” Wikipedia, updated July 3, 2024